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Abstracts of Papers Anaesth Intensive Care 2018 | 46:5 Abstracts of Papers Australian and New Zealand College of Anaesthetists groups before and after the intervention. Annual Scientific Meeting, 7 to 11 May, 2018, Sydney Results: 50 cases were included in the initial audit. Intra- Convention and Exhibition Centre, Sydney, New South operative re-dosing rates were low, with overall compliance Wales of 34% in the January period. The target sample size for the post-intervention period was unable to be reached due to a lack of cases greater than 3 hours' over the audited period. 42 cases were included in the post-intervention analysis. These abstracts are published as supplied and have not been 36% of patients received repeat intra-operative dosing when subjected to editorial review, correction or styling. ANZCA is indicated in the post-intervention group. There was no responsible for obtaining author permissions for publication significant improvement in re-dosing rates post intervention and ethics considerations. [Percentage difference 2%, Chi-squared = 0.04 (95% CI -16.83 to 21.03, p=0.84)]. Conclusion: There was no significant improvement in intra- Improving cephazolin re-dosing practices operative cephazolin re-dosing practices with an educational Dr Luke Anderson (John Hunter Hospital, University of intervention based on audit-feedback cycling and guideline Newcastle, Newcastle, NSW), Dr Robert Marr (Monash dissemination. This is consistent with the low efficacy of Medical Centre, Melbourne, Victoria) educational interventions seen in the literature. Reminder Introduction: Surgical site infection (SSI) is a common, based interventions have been shown to have the greatest preventable cause of post-operative morbidity. Intraoperative effect in improving re-dosing rates. This will form the next re-dosing of cephazolin is recommended for surgical intervention as a part of continued plan-do-study-act (PDSA) procedures extending beyond two half-lives of the drug, to cycling. Due to the absence of electronic intraoperative decrease the risk of SSI. Failure to re-dose is an independent prescribing at our institution, a smartphone app will be risk factor for the development of SSI. Despite re-dosing developed to deliver reminders to clinicians responsible for recommendations, compliance is low, with rates of 20-27% intra-operative re-dosing. reported in the literature. Reminder based interventions have improved re-dosing rates from 20% to 58%. Intraoperative Improving the Fidelity of Cardiopulmonary Exercise Testing decision support systems have led to re-dosing rates of (CPET) for Preoperative Risk Assessment in Major Non- 84-98%. The aim of this project is to improve intraoperative Cardiac Surgery cephazolin re-dosing to comply with guidelines 60-80% of the Dr Jarrod Basto (Peter MacCallum Cancer Centre, University time over a 6 month period. of Melbourne, Melbourne, Victoria), Dr Hilmy Ismail (Peter Method: A retrospective audit of anaesthetic records was MacCallum Cancer Centre, University of Melbourne), Dr conducted to obtain a baseline rate of re-dosing. This was Michael Li (Peter MacCallum Cancer Centre, University of followed by an education-based intervention, consisting of Melbourne), Dr Vladimir Bolshinsky (Peter MacCallum Cancer guideline dissemination and feedback of audit results. Cases Centre, University of Melbourne), Ms Jamie Waterland (Peter performed at John Hunter Hospital from January 1st 2017 to MacCallum Cancer Centre, University of Melbourne), Dr January 31st 2017 were audited to produce baseline data. Alan Herschtal (Peter MacCallum Cancer Centre, University The educational intervention occurred in July 2017, and cases of Melbourne), Dr Kate Burbury (Peter MacCallum Cancer from 1st August 2017 to 31st August 2017 were audited to Centre, University of Melbourne), Professor Alexander Heriot observe the effect of the intervention. Cases were included (Peter MacCallum Cancer Centre, University of Melbourne), if an indication for cephazolin prophylaxis was present, Professor Bernhard Riedel (Peter MacCallum Cancer Centre, the patient was 18 years of age or older, and underwent University of Melbourne) a procedure of greater than 3 hours' duration. Cases were Introduction: The traditional paradigm of preoperative CPET excluded if therapeutic antibiotics were used, cephazolin assessment, established three decades ago, places oxygen was not the recommended agent, the patient had a major consumption (VO2; measured at anaerobic threshold [AT] beta-lactam allergy or cardio-pulmonary bypass was used and peak exercise [pVO2]) at the centre of preoperative (due to prolongation of cephazolin half-life). Sample size risk prediction. VO2, is traditionally dichotomised (AT <10- was calculated to detect a significant change in re-dosing 11 mL.kg.min-1 and pVO2 <16 mL.kg.min-1) for ease of practice for subsequent audit cycles. A sample size of 25 surgical risk prediction [1]. Despite an increasingly elderly was calculated to give a power of 0.8 and a two-sided alpha population with higher comorbid disease burden, surgical of 0.05. This sample size was doubled to 50, to increase and anaesthetic practice continues to evolve and undertake study power. Pearson Chi-square (χ2) test was performed more complex surgery within the framework of sub- to determine any statistically significant difference between specialised care. Within this context, these dichotomised 529 Anaesth Intensive Care 2018 | 46:5 VO2 values may lack diagnostic fidelity to risk-evaluate and Time-driven activity based costing to model the utility of guide patient optimisation prior to major surgery. In non- parallel induction room redesign in high turnover surgical surgical populations, cardiorespiratory disease associates lists with impaired CO2 output [2] and incompetent chronotropic Dr Jarrod Basto (Peter MacCallum Cancer Centre, University response associates with increased mortality. As such, of Melbourne, Melbourne, Victoria), Dr Rani Chahal (Peter we evaluated the utility of: (i) CPET-derived CO2 kinetics MacCallum Cancer Centre, University of Melbourne), (PeCO2; PETCO2; Ve/VCO2) and chronotropic response as risk Professor Bernhard Riedel (Peter MacCallum Cancer Centre, predictors for adverse post-operative outcomes; (ii) standard University of Melbourne) blood tests to improve CPET risk modelling. Introduction: Time-Driven Activity Based Costing (TDABC) Methods: We retrospectively analysed 84 patients is an important tool in quantifying complex costs within undergoing CPET prior to major colorectal surgery. healthcare and has been used to project costs of altered staff Parameters measured: Demographic data, Charlson ratios and workflow modifications prior to implementing Comorbidity Index, conventional preop blood tests process improvements [1]. Under a parallel induction design, (haemoglobin, WCC, neutrophils, albumin) and CPET-derived additional personnel are used to optimise theatre efficiency VO2 (AT, pVO2), VCO2 (VE/VCO2, PETCO2, Pe’CO2), and heart by using an induction room to perform anaesthesia related rate response (HRR) parameters. Postoperative outcomes procedures and induction in subsequent patients but prior assessed: (i) Morbidity using Comprehensive Complication to completing the preceding surgical case. In doing so, the Index (CCI, which considers all Clavien-Dindo graded non-operative time between cases is reduced and this may complications) and (ii) 1-year minimum Overall Survival (OS). potentially improve case throughput [2]. As such, parallel Statistical methods used univariable Cox proportional hazards induction exists in contrast to a traditional serial induction and linear regression analysis. design where patients are induced in theatre sequentially Results: Patients (mean±SD) were 62 (±12) years old, by the same anaesthetic team. Within this context, we used 55% male, 27.8 (±5.6) kg.m-2 BMI and Comprehensive TDABC to model personnel costs and time savings for a high Complication Index (30±19). Univariable modelling showed turnover operating list of breast and melanoma procedures no association between traditional VO2 kinetic parameters under a parallel induction design following an observational and OS (AT; HR=0.89 [0.72-1.10]; p=0.25); pVO2; HR=0.91 trial within theatre. [0.80-1.04]; p=0.15). Peak VO2 corrected for body surface Methods: We instituted an observational trial of serial and area (pVO2/BSA >710mL.min-1.m-2) associated with parallel workflow in theatre among 19 surgical lists (10 reduced postoperative morbidity (p=0.019) and improved OS parallel; 9 serial). Non-operative time was defined from (HR=0.13 [0.03-0.56]; p=0.001). VCO2 kinetics at AT (PETCO2; the final closure of skin until the beginning of surgical HR=0.89 [0.82-0.96]; p=0.004 and PeCO2; HR=0.86 [0.78- preparation. Statistical analysis of non-operative time 0.95]; p=0.003) and HR response to peak exercise (HR=0.10 differences was performed by two-tailed t-tests comparing [0.02-0.48]; p=0.02) were robust predictors of OS. Low mean differences of log-transformed data. Using observed preoperative haemoglobin (p=0.001) and elevated neutrophil process times, we constructed a 6-case model of our all- levels (p=0.01) associated with reduced OS and morbidity, day operating list integrating non-operative time under respectively. Using bivariate analysis, predictive accuracy for either a serial or parallel induction design. Using TDABC we postoperative morbidity and for OS improved significantly subsequently assigned personnel costs to these models based (p<0.01) if pVO2/BSA considered
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